Quality & Patient Safety Registered Nurse (RN)

Gila Regional Medical Center•Silver City, NM

About The Position

The Quality & Patient Safety Registered Nurse supports the organization’s quality improvement, patient safety, regulatory compliance, data management, and continuous survey readiness activities. Working closely with the Director of Quality and organizational leaders, the RN coordinates quality and regulatory projects, supports corrective action plans, monitors compliance, and helps departments improve processes and patient outcomes. The RN collects, abstracts, validates, analyzes, and presents clinical, quality, patient safety, and operational data to identify trends, measure performance, and support organizational decision-making. The position works across clinical applications, regulatory portals, databases, vendor systems, and reporting platforms to ensure information is accurate, complete, and submitted on time. The RN supports and facilitates Root Cause Analyses, Failure Mode and Effects Analyses, process reviews, performance improvement initiatives, regulatory audits, and Joint Commission survey readiness activities. The position coordinates required reporting and submissions to CMS, state agencies, The Joint Commission, and other regulatory bodies. The RN also serves as a resource to departments, translating data, quality standards, regulatory requirements, and performance findings into understandable reports, measurable action plans, and sustainable improvements. The role includes developing and maintaining data tools and regulatory evidence; coordinating survey-readiness projects, audits, tracers, and corrective actions; supporting QAPI and patient safety initiatives; tracking adverse events and quality indicators; preparing reports and presentations; providing education and technical assistance; and coordinating multiple projects and reporting deadlines. The RN protects confidential, peer review, patient safety, quality, and other privileged information in accordance with applicable laws and organizational policies. Other duties consistent with the purpose and level of the position may be assigned.

Requirements

Current New Mexico or multistate Registered Nurse license required.
Bachelor’s degree in nursing, healthcare, quality, health information management, information systems, or a related field required preferred (wording as stated in the posting).
Knowledge of Microsoft Excel, including formulas, sorting and filtering, conditional formatting, charts, pivot tables, lookups, data validation, and reconciliation of large or complex datasets.
Ability to learn and work accurately in multiple software applications, reporting portals, databases, electronic health record modules, and vendor platforms.
Knowledge of healthcare quality measures, regulatory reporting, accreditation standards, data abstraction, validation, and performance improvement methods.
Ability to facilitate or support RCA and FMEA activities using a systems-based, nonpunitive approach.
Strong critical thinking, attention to detail, organization, project coordination, written communication, and presentation skills.
Ability to interpret technical specifications, standards, regulations, policies, and measure manuals and translate them into operational requirements.
Ability to manage competing priorities and recurring deadlines with limited supervision while escalating risks appropriately.
Ability to collaborate professionally with frontline caregivers, providers, leaders, vendors, and external agencies.
Ability to maintain strict confidentiality and use sound judgment when handling sensitive clinical, quality, regulatory, and peer review information.
Quality or patient safety certification, such as CPHQ or CPPS, must be obtained within 2 years.
All required documents must be presented at time of hire.
External applicants’ employment is contingent upon successful completion of pre-employment drug and alcohol testing.

Nice To Haves

Experience with CMS, state, and/or Joint Commission reporting and accreditation activities.
Experience using MEDITECH clinical applications or another electronic health record.

Responsibilities

Collect, abstract, validate, analyze, and report clinical, patient safety, operational, regulatory, and performance improvement data from internal and external sources.
Develop and maintain Excel workbooks, trackers, dashboards, and data-validation tools.
Investigate data discrepancies, missing information, measure logic, and numerator or denominator issues, and coordinate corrections with departments, Information Systems, and vendors.
Identify trends, variation, risks, and improvement opportunities, and present findings to leaders, medical staff, committees, and the Board as assigned.
Maintain data definitions, source documentation, audit trails, and supporting evidence to ensure data integrity and reproducibility.
Coordinate assigned Joint Commission survey-readiness projects, tracers, audits, evidence collection, document control, action plans, and follow-up activities.
Maintain organized and retrievable regulatory evidence, including policies, education records, monitoring results, meeting documentation, corrective actions, and sustainment data.
Assist with mock surveys, onsite survey support, post-survey corrective action documentation, Evidence of Standards Compliance activities, and ongoing compliance monitoring.
Partner with department leaders to translate standards and findings into practical work plans and verify that corrective actions are completed, measured, and sustained.
Support readiness for CMS, state, accreditation, and other external reviews as assigned.
Support and, when assigned, facilitate Root Cause Analyses, apparent cause analyses, FMEAs, PDSA cycles, process mapping, and other performance improvement activities.
Assist teams in identifying contributing factors and system causes and developing measurable corrective actions with assigned owners, completion dates, and effectiveness measures.
Track adverse events, quality indicators, improvement projects, corrective action plans, and patient outcomes.
Support QAPI, patient safety, medical staff quality review, organizational quality goals, and other assigned improvement initiatives.
Protect confidential, peer review, patient safety, quality, and other privileged information in accordance with applicable laws and organizational policies.
Build effective working relationships with clinical and non-clinical departments, Information Systems, Health Information Management, Medical Staff Services, Finance, vendors, and senior leaders.
Coordinate concurrent projects and reporting cycles, establish timelines and deliverables, follow up on outstanding items, and communicate barriers before deadlines are missed.
Prepare accurate reports, presentations, committee materials, and educational resources for Quality, Safety, Performance Improvement, Medical Executive, Board, and other groups as assigned.
Provide education and technical assistance regarding data collection, measure requirements, Excel tools, reporting workflows, and improvement methods.
Perform other duties consistent with the purpose and level of the position.